Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center

Abstract

Objective: To evaluate the impact of changes to urine testing orderables in computerized physician order entry (CPOE) system on urine culturing practices. Design: Retrospective before (January 2015 to April 2016) and after (May 2016 to August 2017) study. Setting: A 1,250-bed academic tertiary referral center. Patients: Hospitalized adults who had ≥1 urine culture performed during their stay. Intervention: The intervention (implemented in April 2017) consisted of notifications to providers, changes to order sets and inclusion of the new urine culture reflex tests in commonly used order sets. We compared the urine culture rates before and after intervention, adjusting for temporal trends. Results: During the study period, 18,954 inpatients (median age 62 years, 68.8% white and 52.3% female) had 24,569 urine cultures ordered. Twenty-seven percent (n=6642) of the urine cultures were positive. Urine culturing rate decreased significantly in the post-intervention period for any specimen type (38.1 pre-vs. 20.9 per 1000 patient days post-intervention, p<0.001), clean catch (30.0 vs. 18.7, p<0.001) and catheterized urine (7.8 vs. 1.9, p<0.001). Using an interrupted time series model, urine culture rates decreased for all specimen types (p<0.05). Conclusions: Our intervention of changes to order sets and inclusion of the new urine culture reflex tests resulted in a 45% reduction in the urine cultures ordered. CPOE system format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.

Incidence and Diagnostic Yield of Repeat Urine Culture in Hospitalized Patients: an Opportunity for Diagnostic Stewardship

“…Other investigators have found similar findings for cardiac enzyme testing and suggested that unnecessary duplicative orders occurred more frequently when patients were transferred from the emergency department to inpatient units (16). The role of computerized physician order entry (CPOE) systems in altering physician ordering practices to reduce unnecessary laboratory testing has been well described (3,8,17). A computerized pop-up alert screen with pending results and the most recent completed test result with the date has resulted in a significant reduction in duplicate orders for ordering of panels of tests for acute hepatitis (17).…”

“…In this study, patients who had an index culture of a sample from an indwelling catheter had a lower risk of having an inappropriate repeat urine culture than those who had an index culture of clean-catch/straight catheterized and procedural specimens. This finding could potentially be explained by our institutional intervention of modifying urine testing order sets in the CPOE system, which was implemented in April 2016 (8). Urinalysis parameters of proteinuria and blood in the urine were excluded from reflex urine culture testing, with the exception of testing for neutropenic patients (8).…”

“…Urinalysis parameters of proteinuria and blood in the urine were excluded from reflex urine culture testing, with the exception of testing for neutropenic patients (8). This CPOE system-based intervention resulted in a significant reduction in the number of indwelling catheterized urine cultures (75.6%) being performed compared to the number of clean-catch urine cultures being performed (37.8%) (8). In our study, we assigned the indwelling catheterized urine cultures to preintervention (January 2015 to April 2016) and postintervention (May 2016 to February 2018) periods, based on our prior institutional intervention (8).…”

“…This CPOE system-based intervention resulted in a significant reduction in the number of indwelling catheterized urine cultures (75.6%) being performed compared to the number of clean-catch urine cultures being performed (37.8%) (8). In our study, we assigned the indwelling catheterized urine cultures to preintervention (January 2015 to April 2016) and postintervention (May 2016 to February 2018) periods, based on our prior institutional intervention (8). We found that the proportion of all indwelling catheterized urine cultures was significantly lower during the postintervention period (3,217/16,308 [19.7%] A limitation of our study is that it is a retrospective study performed at a single, academic hospital, which limits the generalizability of our results to other settings.…”

“…Due to the low numbers of straight catheterized urine cultures (0.3% of all urine cultures), these were grouped together with clean-catch urine cultures. A positive urine culture for all specimen types was defined on the basis of the established clinical breakpoints, as previously published (7,8). We defined a negative urine culture as having insignificant growth below a threshold or no growth.…”